Provider Demographics
NPI:1104947936
Name:PENN, SASHA (OD)
Entity type:Individual
Prefix:
First Name:SASHA
Middle Name:
Last Name:PENN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1945 17TH AVE
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94116-1243
Mailing Address - Country:US
Mailing Address - Phone:415-260-6321
Mailing Address - Fax:415-276-6049
Practice Address - Street 1:3945 PIEDMONT AVE
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94611-5351
Practice Address - Country:US
Practice Address - Phone:510-654-4747
Practice Address - Fax:510-654-0419
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-02
Last Update Date:2022-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12051T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU74645Medicare UPIN
SD0120510Medicare ID - Type Unspecified